Development and Validation of a Five-Factor Sexual

Satisfaction and Distress Scale for Women: The Sexual

Satisfaction Scale for Women (SSS-W)
Cindy Meston, PhD* and Paul Trapnell, PhD†

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Abstract
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Introduction
Sexual satisfaction is a broad construct closely linked to overall relationship
satisfaction [1–5]. Numerous studies have found that sexual satisfaction is
positively associated with indicators of relationship quality such as love [6–
8], commitment [9], and stability [9], and is inversely related to likelihood of
divorce [3,10]. Many factors have been discussed as contributing to a
woman’s sense of sexual satisfaction. These include social factors such as
age, marital status, and income level [11]; personality/affective factors such
as self-esteem [12], sexual guilt [13], selfishness [14], empathy [15],
irritability [5], and anger [16]; and background variables such as physical
affection, positive sexual attitudes in the family of origin [17], and sexual
education [18].
The factor most commonly discussed in relation to sexual satisfaction is
communication between partners. Greater sexual satisfaction has been
reported by married individuals who disclose more about both nonsexual [19]
and sexual aspects of their relationship [19,20]. The results of a telephone
survey of sexuality and marital variables conducted among 996 Canadians
revealed that the item “good sexual communication” was the best predictor of
sexual satisfaction for all subjects except men over the age of 60 years [21].
Effective communication between partners could contribute to sexual
satisfaction by facilitating closeness and intimacy, and by informing partners
about sexual desires and preferences that, in turn, could lead to enhanced
arousal and orgasm. Indeed, feeling incapable of communicating sexual
desires has been a common attribute of orgasm problems, and sexually
assertive women report higher levels of desire, orgasm ability, and sexual
satisfaction [22].
The manner and degree to which women’s sexual satisfaction is linked to
sexual function/dysfunction is not well understood. Findings from studies
that have reported on this relation are generally limited by the lack of
comprehensive and validated measures of sexual dysfunction and/or
satisfaction. Analyses of the U.S. National Health and Social Life Survey
[23] indicated that low desire and arousal concerns were the categories most
strongly associated with dissatisfaction in women. Frank and colleagues [24]
found that sexual dysfunction was also related to dissatisfaction among
married couples, and the relation was particularly strong in women with
arousal problems. Discrepancy between couples in reported levels of sexual
desire has also been negatively associated with sexual satisfaction [25]. In a
study of married Chinese couples, Renaud and Byers [26] reported a
relationship between both one’s and one’s partner’s sexual problems and
sexual satisfaction, and that greater frequency of both affectionate and sexual
behavior was associated with greater sexual satisfaction.
With the increase in research aimed at developing new treatment methods for
women’s sexual dysfunctions over the past several years, a better
understanding of the link between women’s sexual functioning and
satisfaction is called for. While end point criteria for treatment effectiveness
such as increased frequency of sexual thoughts and behaviors, enhanced
genital and subjective arousal, and enhanced orgasm frequency and intensity
are undeniably important considerations, the clinical relevance of such
changes may be questionable if not accompanied by clinically meaningful
improvements in overall sexual satisfaction. Widely accepted as integral to
the diagnosis of most categories of female sexual dysfunction is the notion of
personal distress [27,28]. Yet, to our knowledge, no studies have examined
the relation between what constitutes satisfaction and what constitutes
distress within the sexual realm.
Based on a review of the sexual satisfaction literature [1–26], we propose a
primary distinction between personal and relational components of sexual
satisfaction, both of which, we believe, are necessary to fully understand
what constitutes sexual satisfaction in women. The literature suggests two
main facets of relational sexual satisfaction: communication and
compatibility. Perceived sexual communication is the most frequently cited
contributor of sexual satisfaction in the literature [19–21]. Although
compatibility has not previously been proposed as an umbrella construct, we
believe that global appraisal of compatibility is an important, distinct, and
measurable facet of sexual satisfaction. It reflects frequently described
contributing factors such as perceived compatibility of sexual desire [25],
sexual beliefs, values [29], and attitudes [30,31], and perceived couple
similarity [32]. With regard to personal components of sexual satisfaction,
these would include both global judgements of overall sexual satisfaction
such as that assessed by most current assessment instruments (e.g., Female
Sexual Function Index (FSFI) [33]; Brief Index of Sexual Functioning for
Women [34]), and subjective levels of distress about particular sexual self
concerns.
In this study we present data based on the responses of 886 women who
contributed to the development of the Sexual Satisfaction Scale for Women
(SSS-W). The SSS-W was developed to provide a comprehensive measure of
sexual satisfaction and sexual distress that would benefit researchers and
clinicians interested in further understanding what constitutes sexual
satisfaction in women and how it relates to levels of sexual functioning. In
Phase I of this study, we targeted development of an assessment tool for the
two relational aspects of sexual satisfaction, communication and
compatibility, and one facet of personal sexual satisfaction, global
contentment. In Phase II of this study, we targeted development of an
assessment tool for a second aspect of personal sexual satisfaction, distress.
The final SSS-W scale represents the first multifaceted sexual satisfaction
and distress scale that has been validated on a clinically diagnosed sample of
women with sexual dysfunction.
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Phase I: Initial Item Selection

Methods
Based on recurrent themes in the sexual satisfaction literature, 22 items were
written to represent communication and compatibility dimensions
of relational sexual satisfaction, as well as overall global assessment
of personal sexual satisfaction, which we refer to as “contentment.”
The format of the items was a conventional questionnaire with items
presented as brief descriptive statements to which respondents rate their level
of agreement/disagreement on a 5- point Likert scale. Scale interval anchors
were Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4,
and Strongly Agree = 5. The 22-item questionnaire, a demographics
questionnaire, and several other measures not relevant to the current study
were administered to 538 females enrolled in psychology classes at the
University of British Columbia, Vancouver, Canada in exchange for course
credit. Ethnicity of the participants was 57% Caucasian and 43% Asian.
Subjects ranged in age from 18 to 40 years. Participants completed
questionnaires in groups of 5–10 individuals in large testing rooms. Adequate
space was provided for each participant to maximize privacy. Participants
who registered for these testing sessions were aware of the sexual nature of
the research. Female researchers obtained informed consent, gave
instructions, and answered any questions during the testing sessions. To
ensure confidentiality, each participant was randomly assigned a number
associated with their data. Participants were informed that should they
experience discomfort during the study, they could stop participation without
any academic penalty or loss of credit. Completed questionnaire packets were
placed in a large “drop box” as they left the testing room. Consent forms
were stored separately from the questionnaires to ensure confidentiality. The
research was approved by the University of British Columbia Institutional
Review Board.

Results
We inspected three and four factor solutions, based on unweighted least
squares extraction followed by oblique rotation to simple structure via the
direct oblimin method. Four eigenvalues exceeded a value of 1. The fourth
factor was defined by four items, only one of which loaded >0.50 and two of
which also loaded on additional factors. Because the fourth factor was
weakly defined and difficult to interpret, we opted for a three-factor solution.
The three factors accounted for 54% of the total item variance. Those items
loading most highly and uniquely on each of the three factors were retained
as marker items for each factor. We subsequently decided to collapse two
very similar compatibility items into one item, and made minor wording
changes to a few other items to improve their readability.
Twelve new items were written to address the DSM-rV-TR (American
Psychiatric Association, 1994) diagnostic criterion of personal distress. As
part of an unrelated study, during the clinician- administered DSM-IV-TR
interview, 48 women (age range = 19–53 years; mean age = 32.9 years) who
were diagnosed with Female Sexual Arousal Disorder (FSAD) and/or
Hypoactive Sexual Desire Disorder (HSDD), and/or Female Orgasmic
Disorder (FOD) were asked if they were distressed because of their sexual
difficulties and, if so, why? The 12 distress items were generated based on
their responses. These modifications resulted in a total of 30 items
(contentment = 6, communication = 6, compatibility = 6, concern/distress =
12).
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Phase II: Subscale Addition and Factor Analyses

Methods
Procedure

The revised 30-item SSS-W questionnaire, a demographics questionnaire, the

FSFI [33], and several additional measures not relevant to the current study
were administered to 119 women enrolled in psychology classes at the
University of Texas at Austin during the 2000–2001 school year in exchange
for course credit. The FSFI is a brief, 19-item self-report measure of female
sexual function that provides scores on six domains of sexual function and
has been validated on women with clinically diagnosed FSAD [33], HSDD
[35], and FOD [35]. The testing procedures were identical to that used in
Phase I above. The research was approved by the University of Texas at
Austin Institutional Review Board.
Participants

Subjects were aged 18 years and older, sexually experienced (nonvirgins),

and currently involved in a steady, dating relationship. Thirteen percent of the
women were married; 87% were single. The length of participant’s current
relationship was as follows: 6 months or less, 53%; 6–12 months, 20%; 13
months–5 years, 26%; more than 5 years, 1%. Subjects ranged in age from 18
to 42 years. Ethnic breakdown was: Caucasian 66%, Hispanic 18%, Asian
9%, African American 4%, other 3%. Mean FSFI domain scores were: Desire
4.61, Arousal 5.3, Orgasm 5.2, Pain 5.4, and Satisfaction 5.4. These scores
fall within the range of that reported for sexually functional women [29].

Results
Based on the results of the Phase I factor analysis and the inclusion of new
items to measure concern/distress, we expected that the Phase II items would
exhibit a clear, four-factor structure. We therefore conducted a principle
components analysis on the intercorrelations among the 30 Phase II items,
extracting four factors and rotating the factors to oblique simple structure via
the direct oblimin method. The four factors accounted for 60% of the total
item variance, and the pattern of item loadings on the factors corresponded
closely to the expected factors of Contentment, Compatibility,
Communication, and Concern/Distress (see Table 1).

Table 1
Factor analysis of the 30-item Phase II SSS-W

Factors

Item 1 2 3 4

Contentment
 Factors

Item 1 2 3 4

1. I feel content with my present sex life. 0.86

2. I feel something is missing from my present sex life. −0.83

3. I feel I don’t have enough emotional closeness. −0.69

4. I feel content with the frequency of sexual intimacy. 0.65

5. I don’t have any problems or concerns about sex. 0.62

6. Overall I am satisfied with my sex life. 0.72

Communication

7. My partner gets defensive when discussing sex. −0.52 −0.4

6
 Factors

Item 1 2 3 4

8. My partner and I don’t discuss sex openly. −0.51

9. I usually feel comfortable discussing sex. 0.74 0.34

10. My partner usually feels comfortable discussing sex. 0.68

11. I have no difficulty talking about emotions. 0.62

12. My partner has no difficulty talking about emotions. 0.78

Compatibility

13. Feel partner isn’t sensitive or aware about sexual desires. −0.5 −0.44
8

14. Feel partner and I are not sexually compatible enough. −0.6 −0.37
 Factors

Item 1 2 3 4

15. Partner’s beliefs about sex are too different from mine. −0.5
7

16. I often feel upset about my partner wanting sexual intimacy more often than I −0.6
do. 5

17. I sometimes feel that I am not physically attracted to my partner enough. −0.36 −0.4
2

18. I often wish my partner would be a lot more adventurous and open-minded −0.8
during sex. 1

Concern/Distress

19. Partner will become frustrated. −0.76

 Factors

Item 1 2 3 4

20. Sexual difficulties will adversely affect relationship. −0.78

21. Partner may have an affair. −0.87

22. Partner is sexually unfulfilled. −0.68

23. Partner views me as less of a woman. −0.73

24. I’ve disappointed my partner. −0.28 −0.67

25. I am frustrated with my sexual difficulties. −0.3 −0.50

8

26. I feel sexually unfulfilled. −0.51 −0.30

 Factors

Item 1 2 3 4

27. I wonder if my partner wishes my body were different in some way (e.g. larger −0.53
breasts, smaller waist).

28. I’m worried that my partner is negatively comparing me to past relationships he −0.43 −0.68
has had.

29. I’m worried that my partner will think my sexual difficulties are his/her fault. −0.4 −0.60
9

30. I’m worried that my sexual difficulties have become the focus of my −0.31 −0.35 −0.63
relationship.

Eigenvalue 7.5 5.1 8.0 8.0

Factor loadings <0.25 have been suppressed. Wording of items 1–15, 19–25 have been
abbreviated (see Appendix for full wording). Items were not reverse-scored for the purpose
of the factor analyses. The direction of the factor loadings have been reflected where
necessary such that, in all cases, higher values indicate greater satisfaction.
Although these results supported a multifaceted conception of sexual satisfaction that distinguishes
relational and affective components, they also highlighted potential content distinctions that might
serve as a basis for further refinement and improvement of the scales. Most notably, one item written
to measure distress (#26) loaded instead on the global contentment factor, a result that alerted us to
the preponderance of relational concerns/distress among the candidate distress items, with only one
item targeting self-oriented distress (#26). From a theoretical standpoint we felt it important to
distinguish between concern regarding the well-being of her partner and relationship, and concern
regarding a woman’s own personal erotic pleasure. Together, these considerations led us to construct
equal numbers of personal and relational distress items by dropping four Relational Concern items
having the lowest factor loadings [27,28,29,30], revising the wording of two other Concern items [26,27]
to more clearly target self-oriented distress, and writing four new items to measure self-oriented
distress, thereby resulting in six personal and six Relational Concern items in the final scale. The four
new Concern items (all of which were based on the responses of women interviewed with female sexual
dysfunction (FSD) in Phase I) were: “I’m worried that my sexual difficulties might cause me to seek
sexual fulfillment outside my relationship,” “I’m so distressed about my sexual difficulties that it affects
the way I feel about myself,” “I’m so distressed about my sexual difficulties that it affects my own well-
being,” and “My sexual difficulties annoy and anger me.” Three Compatibility items [16,17,18] were
slightly reworded to increase their readability. The resulting 30-item SSS-W measures five domains of
sexual satisfaction: Contentment, Communication, Compatibility, Relational Concern, and Personal
Concern, with six items per factor.

Go to:

Phase III: Validation on a Clinical Sample of Women with Female Sexual Dysfunction and Age-Matched
Controls

Methods

Procedure

Participants in Phase III were recruited via local radio and newspapers advertisements and were each
paid $50.00 for their participation. Inclusion criteria were: between 18 and 70 years, and currently
involved in a stable, sexually active relationship. Participants who met these criteria were scheduled for
two sessions conducted in the Female Sexual Psychophysiology Laboratory at the University of Texas at
Austin. During the first session, participants were interviewed by a trained clinician to determine
whether or not they met DSM-IV-TR [27] criteria for any of the following: HSDD, FSAD, FOD,
dyspareunia, vaginismus, or sexual anxiety disorder. After the DSM-IV-TR interview, participants filled
out the 30-item revised SSS-W, a demographics questionnaire, the FSFI [33], the Locke Wallace Marital
Adjustment Test (MAT) [36], and some additional measures not relevant to the present study, in a
private and confidential setting. The MAT is a 15-item self-report measure of marital satisfaction or
quality, as well as agreement/disagreement on a number of issues (finances, recreation, affection,
friends, sex, conventionality, conflict resolution, and confiding) and has been shown to reliably
discriminate between maritally satisfied and dissatisfied women [37]. The wording of certain items was
changed from “spouse” to “partner” to account for women who were not married.

Between 4 and 5 weeks after the first session, participants returned for a second session during which
they filled out a second SSS-W as well as additional measures not relevant to the current study. They
were given a chance to ask any questions regarding the study, were debriefed, and paid for their
participation. The research was approved by the University of Texas at Austin Institutional Review Board.

Participants

One hundred and eighty-one women completed the first session of the study. Seventy-nine women did
not meet criteria for HSDD, FSAD, FOD, dyspareunia, vaginismus, or sexual anxiety disorder and were
considered sexually functional (mean age = 27.6 years; range = 18–53 years). One hundred and two
women met criteria for FSD (mean age = 30.0 years, range = 18–56 years). Fifty-five (54%) of the women
with FSD met criteria for FSAD; 47 (46%) met criteria for HSDD; 70 (67%) met criteria for FOD; and 4 (4%)
met criteria for a sexual pain disorder. Fifty-five (54%) of the women with FSD met criteria for more than
one sexual dysfunction (FSAD and FOD, N=14; HSDD and FOD, N=15; FSAD and HSDD, N = 6; FSAD,
HSDD, and FOD, N = 19; FSAD, FOD, and Pain, N= 1). Of the 181 women who completed the first session,
152 returned for a second session. This sample included 86 of the women with FSD and 66 of the control
women.

Participant characteristics are reported in Table 2. An independent samples t-test revealed a trend

toward sexually dysfunctional women being slightly older than sexually functional women, t(1) =
3.62, P = 0.059. Likelihood ratios indicated that the two groups did not significantly differ on
race/ethnicity, LR(4) = 2.55, P = 0.64; education, LR(4) = 3.29, P= 0.51; or use of hormone replacement
therapy, LR(1) = 0.49, P = 0.40. Results from chi-square analyses indicated that the groups did not differ
significantly on annual income, χ2 = 1.50, P =0.47. There was a trend toward more sexually dysfunctional
women being married, χ2 = 5.61, P = 0.06, and receiving antidepressant treatment, LR(1) = 3.63, P =
0.057, compared to functional women. As expected, there were significant group differences in
frequency of sexual activity, χ2 = 14.16, P = 0.007. FSFI domain scores differed significantly between FSD
and control women. Women with sexual dysfunction reported lower levels of desire, arousal,
lubrication, orgasm, satisfaction, and higher levels of sexual pain.

Table 2
Phase III participant characteristics
 FSD N = 102 Controls N = 79 P value

Age 0.06
 FSD N = 102 Controls N = 79 P value

 Mean (± SEM) 30.0 years (0.92) 27.6 years

(0.87)

 Range 18–56 years 18–53 years

Ethnicity N (%) 0.64

 Caucasian 79 (78) 57 (72)

 African American 4 (4) 4 (4)

 Native American 0 (0) 1 (1)

 Hispanic 10 (10) 9 (11)

 Asian 3 (3) 5 (6)

 Other 6 (6) 3 (4)

 FSD N = 102 Controls N = 79 P value

Education N (%) 0.51

 High school/GED 17 (17) 8 (10)

 College 67 (70) 62 (80)

 Graduate school 13 (13) 8 (10)

Annual income N(%) 0.47

 <50,000 56 (57) 50 (64)

 50,000–100,000 31 (31) 18 (23)

 >100,000 12 (12) 10 (13)

Marital status N (%) 0.06

 Married 27 (27) 10 (13)

 FSD N = 102 Controls N = 79 P value

 Divorced 12 (12) 10 (13)

 Single 60 (61) 58 (74)

Children (% Yes) 31 (31) 13 (17) 0.02

Hormone replacement therapy (% 2 (4) 3 (4) 0.40

Yes)

Antidepressant use (% Yes) 9 (9) 2 (3) 0.06

Frequency of sexual activity 0.007

 <once per month 1 (1) 1 (1)

 1–2 per month 20 (20) 6 (8)

 1–2 per week 48 (49) 32 (42)

 FSD N = 102 Controls N = 79 P value

 3–4 per week 25 (25) 22 (29)

 >4 per week 5 (5) 16 (21)

FSFI domain scores* (Mean ± SEM)

 Desire 3.57 (0.12) 4.56 (0.10) <0.001

 Arousal 3.88 (0.13) 5.30 (0.08) <0.001

 Lubrication 4.23 (0.16) 5.54 (0.08) <0.001

 Orgasm 3.38 (0.16) 5.24(0.11) <0.001

 Pain 5.05 (0.14) 5.74 (0.10) <0.001

 Satisfaction 3.98 (0.14) 4.93 (0.13) <0.001

The FSFI scores reported here were included in the calculation of the FSFI scores reported in Meston (2003).
*
Higher scores represent higher levels of function for all domains except Pain.
Results

Factor Analyses

In view of our Phase II factor analysis results and our revisions to the
concern/distress items, we expected that intercorrelations among the final 30
SSS-W items would demonstrate a clear, five-factor structure. To evaluate
this, we first conducted a principal components analysis using the combined
sample of FSD and control women. The five factors accounted for 63% of the
total item variance. The pattern of factor loadings in the combined sample
corresponded clearly to the scale assignments described in Phase II: all items
loaded most highly on their assigned factors with the exception of two
Contentment items, one of which loaded most highly on the Relational
Concern factor (“I feel I don’t have enough emotional closeness”) while the
other loaded most highly on the Personal Concern factor (“I don’t have any
problems or concerns about sex”). One Personal Concern item cross-loaded
highly on the Compatibility factor (“I may have an affair”).
Next, using only the data for FSD women, we conducted a principal
components analysis on the SSS-W item intercorrelations, extracting five
factors and rotating the factors to oblique simple structure via the direct
oblimin method. Item loadings of the resulting five factors are presented
in Table 3. The five factors accounted for 57% of the total item variance. The
first four factors were similar to those obtained in Phase II for sexually
functional women, although the global sexual Contentment factor is less well
defined here, and two of the Communication items referring to “discussing
sex” loaded more highly on the Contentment factor than on the
Communication factor. As expected, however, items representing personal
concerns defined a different factor from items representing relational
concerns, indicating that these sources of sexual dissatisfaction are
reasonably distinct among women diagnosed with sexual disorders.

Table 3
Factor analysis of the Phase III final 30 questions of the SSS-W in women
with FSD
 Factors

Item 1 2 3 4 5

Contentment

1. I feel content with my present sex life. 0.53 0.34

2. I feel something is missing from my present sex life. −0.38 −0.3 −0.2
0 9

3. I feel I don’t have enough emotional closeness. −0.36 −0.4

0

4. I feel content with the frequency of sexual intimacy. 0.59

5. I don’t have any problems or concerns about sex. 0.69

6. Overall I am satisfied with my sex life. 0.59 0.44

Communication
 Factors

Item 1 2 3 4 5

7. My partner gets defensive when discussing sex. −0.61

8. My partner and I don’t discuss sex openly. −0.61 −0.3

5

9. I usually feel comfortable discussing sex. 0.69

10. My partner usually feels comfortable discussing sex. 0.42 0.53

11. I have no difficulty talking about emotions. 0.73

12. My partner has no difficulty talking about emotions. 0.70

Compatibility
 Factors

Item 1 2 3 4 5

13. Feel partner isn’t sensitive or aware about sexual −0.33

desires.

14. Feel partner and I are not sexually compatible enough. −0.74

15. Partner’s beliefs about sex are too different from mine. −0.59

16. Partner and I mismatched in sexual intimacy needs. −0.82

17. Partner and I not physically attracted enough. −0.37

18. Partner and I mismatched in sexual preferences. −0.86

Relational concern

19. Partner will become frustrated. −0.8

 Factors

Item 1 2 3 4 5

20. Sexual difficulties will adversely affect relationship. −0.8

4

21. Partner may have an affair. −0.3 −0.5

6 0

22. Partner is sexually unfulfilled. −0.7

7

23. Partner views me as less of a woman. −0.4

7

24. I’ve disappointed my partner. −0.8

0

Personal concern
 Factors

Item 1 2 3 4 5

25. My sexual difficulties are frustrating to me. −0.79

26. My sexual difficulties make me feel sexually unfulfilled. −0.80

27. I may have an affair. −0.48 −0.28

28. My sexual difficulties affect how I feel about myself. −0.82

29. My sexual difficulties affect my well-being. −0.69

30. My sexual difficulties annoy and anger me. −0.77

Eigenvalue 3.9 2.7 4.6 4.5 5.0

Questions 1–30 are abbreviated (see Appendix for full wording of items).

Factor loadings <0.25 have been suppressed. Items were not reverse-scored for the purpose of the factor analyses.
The direction of the factor loadings have been reflected where necessary such that, in all cases, higher values
indicate greater satisfaction.

Separate domain scales to represent the five factors of Contentment,

Communication, Compatibility, Relational Concern, and Personal Concern
were scored by summing responses to the six constituent items assigned to
each domain (see Table 3). Intercorrelations among the resulting five scales
are presented in Table 4. In general, intercorrelations among the scales
tended to be lower among FSD women than control group women,
suggesting that FSD women had more distinguishable sources of sexual
dissatisfaction than sexually functional women. Correlations between
Contentment and the remaining domains were moderate to high in
magnitude for both FSD and control group women. Correlation between
Communication and Compatibility were relatively similar for FSD (r = 0.50)
and control group women (r = 0.54). Personal Concern showed a relatively
low correlation with Communication and Compatibility among FDS women
(r = 0.14 and r = 0.25, respectively) and control group women (r = 0.21 and r
= 0.23, respectively). Relational Concern was moderately correlated with
Contentment among control group women (r = 0.45), but not among FSD
women (r = 0.14).

Table 4

Phase III domain intercorrelations

Contentmen
t Communication Compatibility Relational concern Personal concern

Combined sample
 Contentmen
t Communication Compatibility Relational concern Personal concern

 Contentment 1.00

 Communication 0.52* 1.00

 Compatibility 0.67* 0.56* 1.00

 Concern: 0.61* 0.33* 0.46* 1.00

Relational

 Concern: Personal 0.70* 0.31* 0.47* 0.66* 1.00

Female Sexual Dysfunction

 Contentment 1.00

 Communication 0.30* 1.00

 Compatibility 0.48* 0.50* 1.00

 Contentmen
t Communication Compatibility Relational concern Personal concern

 Concern: 0.41* 0.14 0.30* 1.00

Relational

 Concern: Personal 0.56* 0.14 0.25* 0.35* 1.00

Controls

 Contentment 1.00

 Communication 0.71* 1.00

 Compatibility 0.66* 0.54* 1.00

 Concern: 0.50* 0.45* 0.26* 1.00

Relational

 Concern: Personal 0.47* 0.21 0.23 0.67* 1.00

Reliability

Cronbach’s coefficient alpha for the SSS-W domain and total scales are
presented in Table 5. In the combined sample, values exceeded 0.80 for all
scales except Communication (0.74). In the FSD and control samples, values
exceed 0.80 for all scales except Contentment (0.75 and 0.79, respectively)
and Communication (both 0.72). The latter values are moderate but
satisfactory for very short scales measuring a reasonably broad range of
content.

Table 5
Phase III domain characteristics: Reliability

Internal consistency† Test–retest reliability‡

Combined sample FSD Controls Combined sample FSD Controls

Domain N = 181 N = 102 N = 79 N = 152 N= N=66

86

 Contentment 0.83 0.75 0.79 0.80* 0.65* 0.76*

 Communication 0.74 0.72 0.72 0.63* 0.62* 0.58*

 Compatibility 0.85 0.81 0.82 0.78* 0.74* 0.72*

 Concern: 0.88 0.85 0.80 0.86* 0.79* 0.72*

Relational
 Internal consistency† Test–retest reliability‡

Combined sample FSD Controls Combined sample FSD Controls

 Concern: Personal 0.90 0.81 0.88 0.83* 0.73* 0.72*

Total score 0.94 0.88 0.91 0.87* 0.76* 0.79*

*
Correlation significant at P< 0.01.
†
Cronbach’s alpha (range = −1.00 to +1.00).
‡
Pearson product-moment correlation coefficient (range = 0 + 1.00).

Test–retest reliability (test stability across time) was assessed by comparing

the SSS-W domain and total scores from the first session with those obtained
4–5 weeks later during the second session. As can be seen in Table 5, test–
retest reliability was significant and moderately high for all domains among
women with FSD (r = 0.62–0.79) and control women (r = 0.58–0.79). The
highest test–retest reliability was seen among sexually dysfunctional women
for the Relational Concern domain (r = 0.80).
Concurrent Validity

The ability of the SSS-W to differentiate between sexually functional and

dysfunctional women was assessed by comparing the mean responses of
women with FSD with those of the control women. The results from
between-groups analyses of variance revealed significant differences between
women with FSD and controls on each of the five SSS-W domains and total
score (See Table 6 for means [± SEMs] of the SSS-W items, domains, and
total scores by participant group). Not surprisingly, the largest difference
between groups was seen for the Personal Concern domain F(1,156) =
106.43, P< 0.001.
Table 6
Phase III concurrent validity

FSD Mean (± Controls Mean (±

Item SEM) SEM) P value

Contentment <0.001

1. I feel content with my present sex life. 2.3 (0.13) 3.9 (0.15)

2. I feel something is missing from my present sex life. 2.2 (0.14) 3.2 (0.16)

3. I feel I don’t have enough emotional closeness. 3.2 (0.15) 3.5 (0.17)

4. I feel content with the frequency of sexual intimacy. 2.6 (0.14) 3.7 (0.15)

5. I don’t have any problems or concerns about sex. 1.7 (0.09) 3.5 (0.16)

6. Overall I am satisfied with my sex life. 2.6 (0.10) 3.8 (0.09)

Communication <0.001
 FSD Mean (± Controls Mean (±
Item SEM) SEM) P value

7. My partner gets defensive when discussing sex. 4.0 (0.13) 4.4 (0.11)

8. My partner and I don’t discuss sex openly. 3.8 (0.15) 4.2 (0.14)

9. I usually feel comfortable discussing sex. 4.0 (0.13) 4.6 (0.10)

10. My partner usually feels comfortable discussing sex. 3.8 (0.13) 4.4 (0.11)

11. I have no difficulty talking about emotions. 3.3 (0.15) 3.8 (0.15)

12. My partner has no difficulty talking about emotions. 3.0 (0.16) 3.4 (0.15)

Compatibility <0.001

13. Feel partner isn’t sensitive or aware about sexual 2.9 (0.14) 4.0 (0.15)
desires.

14. Feel partner and I are not sexually compatible 3.3 (0.14) 4.5 (0.11)
enough.
 FSD Mean (± Controls Mean (±
Item SEM) SEM) P value

15. Partner’s beliefs about sex are too different from 3.4 (0.15) 4.1 (0.14)
mine.

16. Partner and I mismatched in sexual intimacy needs. 3.0 (0.14) 4.2 (0.13)

17. Partner and I not physically attracted enough. 3.8 (0.13) 4.2 (0.13)

18. Partner and I mismatched in sexual preferences. 3.1 (0.14) 4.2 (0.14)

Relational concern <0.001

19. Partner will become frustrated. 2.6 (0.14) 4.3 (0.13)

20. Sexual difficulties will adversely affect relationship. 2.6 (0.14) 4.2 (0.14)

21. Partner may have an affair. 4.1 (0.13) 4.7 (0.08)

22. Partner is sexually unfulfilled. 2.9 (0.15) 4.2 (0.12)

 FSD Mean (± Controls Mean (±
Item SEM) SEM) P value

23. Partner views me as less of a woman. 4.0 (0.13) 4.7 (0.09)

24. I’ve disappointed my partner. 2.7 (0.14) 4.4 (0.12)

Personal concern <0.001

25. Sexual difficulties are frustrating to me. 1.5 (0.09) 3.8 (0.17)

26. Sexual difficulties make me feel sexually unfulfilled. 2.1 (0.13) 4.0 (0.15)

27. I may have an affair. 3.5 (0.17) 4.4 (0.14)

28. Sexual difficulties affect how I feel about myself. 2.9 (0.15) 4.2 (0.15)

29. Sexual difficulties affect my well-being. 3.3 (0.14) 4.4 (0.13)

30. Sexual difficulties annoy and anger me. 2.5 (0.15) 4.2 (0.16)
 FSD Mean (± Controls Mean (±
Item SEM) SEM) P value

Total score 88.8 (2.06) 123.4 (2.30)

Questions 1–30 are abbreviated (see Appendix for full wording of items). All negative keyed items have been
reverse-scored in the satisfaction direction such that higher means indicate higher levels of satisfaction.

Convergent/Discriminant

Convergent validity was assessed by calculating relations between the five

SSS-W domain and total scores and the FSFI Satisfaction domain scores.
Pearson correlations were conducted on 75 control women and 97 women
with FSD for whom data were available for both the SSS-W and FSFI. In
general, correlations between scales were higher for sexually functional
women (r = 0.29–0.70) than for sexually dysfunctional women (r = 0.22–
0.46). The Contentment domain showed the highest correlation with FSFI
Satisfaction for both FSD and control women, and the Relational Concern
domain showed the lowest association with FSFI Satisfaction among both
functional and dysfunctional women (see Table 7).

Table 7
Phase III domain characteristics: Convergent/discriminant validity

FSFI satisfaction domain Marital adjustment test

Combined sample FSD Controls Combined sample FSD Controls

Domain N = 172 N= N = 75 N = 170 N = 96 N = 74

 FSFI satisfaction domain Marital adjustment test

Combined sample FSD Controls Combined sample FSD Controls

97

 Contentment 0.63* 0.46* 0.70* 0.36* 0.24* 0.50*

 Communication 0.46* 0.36* 0.48* 0.52* 0.57* 0.41*

 Compatibility 0.54* 0.39* 0.61* 0.57* 0.58* 0.57*

 Concern: 0.38* 0.22* 0.29* 0.23* 0.21* 0.15

Relational

 Concern: Personal 0.46* 0.27* 0.40* 0.19* 0.09 0.16

Total score 0.61* 0.45* 0.63* 0.46* 0.79* 0.47*

*
P<0.01.

We evaluated the discriminant validity of the SSS-W domain scales by

examining their correlation with a related, but different, construct—marital
satisfaction. For reasons detailed in the Introduction, we expected a certain
degree of positive association between all SSS-W domains and marital
satisfaction. However, we anticipated that these associations would tend to be
stronger for relationship evaluative components of sexual satisfaction
(compatibility and communication) than for overt distress components
(personal and interpersonal distress). Because global ratings of sexual
contentment logically involve both of these components, we expected the size
of the marital satisfaction correlation with Contentment to be intermediate in
magnitude between that obtained for the relational and distress domains. Data
for both the SSS-W and MAT were available for 74 control women, and 96
women with FSD. Among women with FSD, significant correlations were
noted for all SSS-W domains except Personal Concern. Among control
women, significant correlations were noted for all SSS-W domains except
Relational Concern and Personal Concern. In general, the correlations were
in the low to moderate range (see Table 7).
To further explore the pattern of associations between SSS-W subscales and
these criteria, we conducted a simultaneous multiple regression of the SSS-W
subscale scores on the MAT and FSFI Satisfaction domain scores. The SSS-
W domain scores explained 42% of MAT score variance, with this
association attributable solely to the two relationship evaluative domains,
SSS-W Communication (β = 0.312, P = 0.000) and Compatibility (β =
0.492, P = 0.000); beta weights for the remaining domains were not
significantly different from zero (Contentment: β =−0.048, P = 0.670;
Relational Concern: β = 0.008, P = 0.932; Personal Concern: β = −0.121, P =
0.215). SSS-W domain scores explained 40% of FSFI Satisfaction domain
score variance, with that association attributable primarily to SSS-W
Contentment (β = 0.412, P= 0.000) and also to Compatibility (β = 0.207, P =
0.028); beta weights for the remaining SSS-W domains were not significantly
different from zero (Communication: β = 0.102, P= 0.221; Relational
Concern: β = −0.087, P = 0.337; Personal Concern: β = 0.096, P = 0.321).
Go to:

Discussion
The purpose of the current study was to develop a comprehensive, valid, and
reliable self-report measure of women’s sexual satisfaction. Phase I of this
study involved the initial selection of items based on past literature on sexual
satisfaction and an exploratory factor analysis (N = 538) of the SSS-W which
resulted in two relational (communication, compatibility) and one personal
(contentment) sexual satisfaction domains that were supported by factor
analyses. Also, in Phase I additional items based on interviews of women
with diagnosed sexual dysfunction were written to address a second domain
of personal sexual satisfaction, namely distress. Phase II involved an
additional administration of the SSS-W (N = 119) and further refinement of
the questionnaire items that resulted in two relational and two personal
domains supported by factor analyses: communication, compatibility,
contentment, and concern. Phase III involved refinement of the concern
questions, the addition of items addressing personal concern regarding
relationship issues, and administration of the final 30-item SSS-W to a
sample of women with clinically diagnosed sexual dysfunction and controls
(N = 181).
The final 30-item SSS-W consists of five domains (two relational; three
personal) of six items each: communication, compatibility, contentment,
relational concern, and personal concern. Items in the communication,
compatibility, and contentment domains were written to reflect themes
relating to sexual satisfaction noted in prior literature. Specifically, these
domains include items relating to ease and comfort such as discussing sexual
and emotional issues (communication), compatibility between partners in
terms of sexual beliefs, preferences, desires, and attraction (compatibility),
and overall global contentment with emotional and sexual aspects of the
relationship (contentment). In two separate factor analyses of 538 and 119
sexually functional women, the items in these three domains loaded
consistently on the same factors. When administered to a group of sexually
dysfunctional women, the pattern was somewhat less clear, with several
items in the Contentment and Communication domains loading on different
factors. These exceptions were however, theoretically interpretable. For
example, the Contentment item referring to “emotional closeness” loaded
most highly on Compatibility and Relational Concern; the Contentment item
“something is missing from my sex life” loaded equally on Contentment,
Compatibility, and Relational Concern. In addition, domain intercorrelations
between contentment, communication, and the three other domains were low
to moderate among women with FSD (0.14–0.56), providing additional
support for the independence of these factors.
Items in the personal sexual satisfaction domains of Relational Concern and
Personal Concern were written based on the responses of women with
diagnosed sexual dysfunction who replied to the question “Do your sexual
concerns distress you? If so, why?” This aspect of sexual satisfaction was
included to specifically address the diagnostic criterion “personal distress.”
To our knowledge, only one study to date has empirically addressed the issue
of personal distress. In a well-designed series of studies, Derogatis and
colleagues [38] presented data supporting the validity and reliability of a 12-
item unidimensional measure of personal distress. We believe that the
findings reported here support the distinction between personal and relational
aspects of distress. Responses from the women experiencing sexual
dysfunction revealed distress specifically concerning their personal well-
being and sexual fulfillment, and distress regarding the impact of their sexual
problems on their partner and relationship at large. The results of two
separate factor analyses provided support for these two distinct distress
factors. We believe that determining whether a woman is distressed for
personal or relational reasons could substantially impact her motivation
toward treatment and, consequently, the likelihood of treatment efficacy.
Psychometric evaluation of the final 30-item SSS-W in a sample of women
meeting DSM-IV-TR criteria for female sexual dysfunction, and in a control
sample provided preliminary evidence of the measures reliability and
validity. Internal consistency coefficients (Cronbach’s alpha) were in the
acceptable range for all domains among both sexually functional and
dysfunctional women. Correlations between initial SSS-W responses and
those obtained 4–5 weeks later were in the moderate range for functional and
dysfunctional women demonstrating acceptable stability of the SSS-W across
measurement intervals. In terms of concurrent and divergent validity,
correlations between the FSFI Satisfaction domain and SSS-W domain scores
varied substantially. In women with FSD and control women, FSFI
Satisfaction was moderately correlated with the SSS-W Contentment domain.
With the exception of the Compatibility domain, which was also moderately
correlated with FSFI Satisfaction in control women, the remaining factors
showed only weak correlations with the FSFI Satisfaction domain among
functional and dysfunctional women. These findings support the need for a
comprehensive measure of sexual satisfaction. Divergence of the SSS-W
from marital satisfaction was indicated by low to moderate correlations
between SSS-W domain scores and scores on the Locke-Wallace marital
adjustment scale for both FSD and control women. On the other hand,
regressions of SSS-W domains on global marital satisfaction and global
sexual satisfaction revealed a divergent pattern of relations for the SSS-W
domains that supports a basic distinction between affective and relational
components of sexual satisfaction.
Domain intercorrelations were generally lower for the FSD versus control
group, suggesting that sexual satisfaction may be a more unified construct
among sexually functional than dysfunctional women. The ability of the SSS-
W to discriminate between sexually functional women and women clinically
diagnosed with a sexual dysfunction was demonstrated for each of the SSS-
W domain scores as well as for the total score.
Go to:

Conclusions
The items that comprise the SSS-W were written based on recurrent themes
in the sexual satisfaction literature, and on interviews of women diagnosed
with female sexual dysfunction. We used an analogue sample of university
women to provide preliminary psychometric evidence of distinct relational
and personal aspects of sexual satisfaction in women, and a clinical sample to
provide preliminary evidence of the scale’s construct validity. The final SSS-
W represents a brief, 30-item, multifaceted measure of women’s sexual
satisfaction. It exhibits sound psychometric properties and has a
demonstrated ability to discriminate between clinical and nonclinical
populations. Further research in a clinical sample is needed to test whether
the sexual satisfaction distinctions proposed in this study are effective in
providing further insight into clinical aspects of sexual satisfaction in women.
Go to:

Acknowledgments
Phase III of this publication was made possible by Grant Number 5 ROl
AT00224-02 from the National Center for Complementary and Alternative
Medicine to the first author. Its contents are solely the responsibility of the
authors and do not necessarily represent the official views of the National
Center for Complementary and Alternative Medicine.
Question Response options

Q1: I feel content with the way my present sex life is. 1 = Strongly disagree
2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
5 = Strongly agree

Q2: I often feel something is missing from my present sex life. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q3: I often feel I don’t have enough emotional closeness in my sex life. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q4: I feel content with how often I presently have sexual intimacy (kissing, intercourse, 1 = Strongly disagree
etc.) in my life. 2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
Question Response options

5 = Strongly agree

Q5: I don’t have any important problems or concerns about sex (arousal, orgasm, 1 = Strongly disagree
frequency, compatibility, communication, etc.). 2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
5 = Strongly agree

Q6: Overall, how satisfactory or unsatisfactory is your present sex life? 5 = Completely
satisfactory
4 = Very satisfactory
3 = Reasonable
satisfactory
2 = Not very
satisfactory
1 = Not at all
satisfactory

Q7: My partner often gets defensive when I try discussing sex. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a litte
1 = Strongly agree
Question Response options

Q8: My partner and I do not discuss sex openly enough with each other, or do not discuss 5 = Strongly disagree
sex often enough. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q9: I usually feel completely comfortable discussing sex whenever my partner wants to. 1 = Strongly disagree
2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
5 = Strongly agree

Q10: My partner usually feels completely comfortable discussing sex whenever I want to. 1 = Strongly disagree
2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
5 = Strongly agree

Q11: I have no difficulty talking about my deepest feelings and emotions when my partner 1 = Strongly disagree
wants me to. 2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
Question Response options

5 = Strongly agree

Q12: My partner has no difficulty talking about their deepest feelings and emotions when I 1 = Strongly disagree
want him to. 2 = Disagree a little
3 = Neither agree or
disagree
4 = Agree a little
5 = Strongly agree

Q13: I often feel my partner isn’t sensitive or aware enough about my sexual likes and 5 = Strongly disagree
desires. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q14: I often feel that my partner and I are not sexually compatible enough. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q15: I often feel that my partner’s beliefs and attitudes about sex are too different from 5 = Strongly disagree
mine. 4 = Disagree a little
Question Response options

3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q16: I sometimes think my partner and I are mismatched in needs and desires concerning 5 = Strongly disagree
sexual intimacy. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q17: I sometimes feel that my partner and I might not be physically attracted to each other 5 = Strongly disagree
enough. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q18: I sometimes think my partner and I are mismatched in our sexual styles and 5 = Strongly disagree
preferences. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree
Question Response options

Q19: I’m worried that my partner will become frustrated with my sexual difficulties. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q20: I’m worried that my sexual difficulties will adversely affect my relationship. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q21: I’m worried that my partner may have an affair because of my sexual difficulties. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q22: I’m worried that my partner is sexually unfulfilled. 5 = Strongly disagree

4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
Question Response options

1 = Strongly agree

Q23: I’m worried that my partner views me as less of a woman because of my sexual 5 = Strongly disagree
difficulties. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q24: I feel like I’ve disappointed my partner by having sexual difficulties. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q25: My sexual difficulties are frustrating to me. 5 = Strongly disagree

4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q26: My sexual difficulties make me feel sexually unfulfilled. 5 = Strongly disagree

4 = Disagree a little
Question Response options

3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q27: I’m worried that my sexual difficulties might cause me to seek sexual fulfillment 5 = Strongly disagree
outside my relationship. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q28: I’m so distressed about my sexual difficulties that it affects the way I feel about 5 = Strongly disagree
myself. 4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Q29: I’m so distressed about my sexual difficulties that it affects my own well-being. 5 = Strongly disagree
4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree
Question Response options

Q30: My sexual difficulties annoy and anger me. 5 = Strongly disagree

4 = Disagree a little
3 = Neither agree or
disagree
2 = Agree a little
1 = Strongly agree

Scoring System

Domain Questions Score range

Contentment 1,2,3,4,5,6 6–30

Communication 7,8,9,10,11,12 6–30

Compatibility 13,14,15,16,17,18 6–30

Concern— 19,20,21,22,23,24 6–30

Relational
 Scoring System

Domain Questions Score range

Concern—Personal 25,26,27,28,29,30 6–30

Individual domain scores are computed by adding the scores of the individual items that comprise the domain. Full
Scale Score = (Contentment + Communication + Compatibility + (Relational Concern + Personal Concern/2)).

References
1. Blumstein P, Schwartz P. American couples. New York: William Morrow;
1983. [Google Scholar]

2. Cupach WR, Comstock J. Satisfaction with sexual communication in

marriage: Links to sexual satisfaction and dyadic adjustment. Journal of
Social and Personal Relationships. 1990;7:179–86. [Google Scholar]

3. Edwards JN, Booth A. Sexuality, marriage, and well-being: The middle

years. In: Rossi AA, editor. Sexuality across the life course. Chicago:
University of Chicago Press; 1994. pp. 233–59. [Google Scholar]

4. Greenly AM. Faithful attraction: Discovering intimacy, love, and fidelity in

American marriage. New York: Doherty; 1991. [Google Scholar]

5. Henderson-King DH, Veroff J. Sexual satisfaction and marital well-being in

the first years of marriage. Journal of Social and Personal
Relationships. 1994;11:509–34. [Google Scholar]

6. Aron A, Henkemeyer L. Marital satisfaction and passionate love. Journal of

Social and Personal Relationships. 1995;12:139–46. [Google Scholar]
7. Grote NK, Frieze IH. Remembrance of things past: Perceptions of marital
love from its beginnings to the present. Journal of Social and Personal
Relationships. 1998;15:91–109. [Google Scholar]

8. Yela C. Predictors of and factors related to loving and sexual satisfaction

for men and women. Eur Rev Appl Psyc. 2000;50:235–43. [Google Scholar]

9. Sprecher S. Sexual satisfaction in premarital relationships: Associations

with satisfaction, love, commitment, and stability. J Sex Res. 2002;39:190–
6. [PubMed] [Google Scholar]

10. White L, Keith B. The effect of shift work on the quality and stability of
marital relations. J Mar Fam. 1990;52:453–62. [Google Scholar]

11. Christopher FS, Sprecher S. Sexuality in marriage, dating, and other

relationships: A decade review. J Mar Fam. 2000;62:999–1017. [Google
Scholar]

12. Larson JH, Anderson SM, Holman TB, Niemann BK. A longitudinal study
of the effects of premarital communication, relationship stability, and self-
esteem on sexual satisfaction in the first year of marriage. J Sex Marit
Ther. 1988;24:193–206. [PubMed] [Google Scholar]

13. Lee HT. Variables of subjective sexual desire and satisfaction in a large

sample of married couples from North American evangelical Christian
congregations. Dissertation abstracts international: Section B: The sciences
and engineering. 1995 November;56(5-B) [Google Scholar]

14. McCann JR, Biaggio MK. Sexual satisfaction in marriage as a function of

life meaning. Arch Sex Behav. 1989;18:59–72. [PubMed] [Google Scholar]

15. Song J, Bergen MB, Schumm WR. Sexual satisfaction among Korean-

American couples in the Mid-western United States. J Sex Marit
Ther. 1995;21:147–58. [PubMed] [Google Scholar]
16. Belanger C, Laughrea K, Lafontaine M. The impact of anger on sexual
satisfaction in marriage. Can J Hum Sex. 2001;10:91–9. [Google Scholar]

17. Bridges SPK. Predicting and describing sexual satisfaction in women:

Physical affection in family of origin, sexual initiation and communication,
and masturbatory practices. Dissertation abstracts international: Section B:
The sciences and engineering. 2000 March;60(8-B) [Google Scholar]

18. Supekova M, Bianchi G. Sexual education and satisfaction of sexually

more active young people: A qualitative approach. Ceskoslovenska
Psychologie. 2000;44:46–76. [Google Scholar]

19. Byers ES, Demmons S. Sexual satisfaction and sexual self-disclosure

within dating relationships. J Sex Res. 1999;36:180–9. [Google Scholar]

20. Purnine DM, Carey MP. Interpersonal communication and sexual

adjustment: The roles of under-standing and agreement. J Consult Clin
Psychol. 1997;65:1017–25. [PMC free article] [PubMed] [Google Scholar]

21. Trudel G. Sexuality and marital life: Results of a survey. J Sex Marit

Ther. 2002;28:229–49. [PubMed] [Google Scholar]

22. Huberle DF. The role of assertiveness in female sexuality: A comparative

study between sexually assertive and sexually nonassertive women. J Sex
Marit Ther. 1991;17:183–90. [PubMed] [Google Scholar]

23. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States:
Prevalence and predictors. JAMA. 1999;281:537–44. [PubMed] [Google
Scholar]

24. Frank E, Anderson C, Rubenstein D. Frequency of sexual dysfunctions in

“normal” couples. N Engl J Med. 1978;229:111–5. [PubMed] [Google
Scholar]
25. Davies S, Katz J, Jackson JL. Sexual desire discrepancies: Effects on sexual
and relationship satisfaction in heterosexual dating couples. Arch Sex
Behav. 1999;28:553–67. [PubMed] [Google Scholar]

26. Renaud C, Byers ES. Sexual and relationship satisfaction in mainland

China. J Sex Res. 1997;34:399–410. [Google Scholar]

27. American Psychiatric Association. Diagnostic and statistical manual of

mental disorders. 4. Washington, DC: Author; 2000. text revision. [Google
Scholar]

28. Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K,

Graziottin A, Heiman J, Laan E, Meston CM, van Lankveld J, Weijmar Schultz
W. Definitions of women’s sexual dysfunction reconsidered: Advocating
expansion and revision. J Psychosom Obstet Gynec. 2003;24:221–
9. [PubMed] [Google Scholar]

29. Kenny D, Acitelli LK, Weiner D. The importance of similarity and

understanding of partners’ marital ideals to relationship
satisfaction. Personal Relationships. 2001;8:167–85. [Google Scholar]

30. Cupach WR, Metts S. The role of sexual attitude similarity in romantic

heterosexual relationships. Personal Relationships. 1995;2:287–300. [Google
Scholar]

31. Karney BR, Bradbury IN. The longitudinal course of marital quality and
stability: A review of theory, method, and research. Psych Bull. 1995;118:3–
34. [PubMed] [Google Scholar]

32. Weisfeld GE, Russell RJ, Weisfeld CC, Wells PA. Correlates of satisfaction
in British marriages. Ethol Sociobio. 1992;13:125–45. [Google Scholar]

33. Rosen R, Brown C, Heiman J, Leiblum S, Meston CM, Shabsigh R,

Ferguson D, D’Agostino R., Jr The Female Sexual Function Index (FSFI): A
multidimensional self-report instrument for the assessment of female sexual
function. J Sex Marit Ther. 2000;26:191–208. [PubMed] [Google Scholar]

34. Taylor JR, Rosen RC, Leiblum SR. Self-report assessment of female sexual
function: Psychometric evaluation of the brief index of sexual functioning for
women. Arch Sex Behav. 1994;23:627–43. [PubMed] [Google Scholar]

35. Meston CM. Validation of the Female Sexual Function Index (FSFI) in

women with Hypoactive Sexual Desire Disorder and in Women with Female
Orgasmic Disorder. J Sex Marit Ther. 2003;29:39–46. [PMC free
article] [PubMed] [Google Scholar]

36. Locke H, Wallace K. Short marital adjustment and prediction tests: Their

reliability and validity. Marriage Fam Living. 1959;2:251–5. [Google Scholar]

37. Freeston MH, Plechaty M. Reconsideration of the Locke-Wallace Marital

Adjustment Test: Is it still relevant for the 1990s? Psych Rep. 1997;81:419–
34. [PubMed] [Google Scholar]

38. Derogatis LR, Rosen R, Leiblum S, Burnett A, Heiman J. The female

distress scale (FSDS): Initial validation of a standardized scale for assessment
of sexually related personal distress in women. J Sex Marit
Ther. 2002;28:317–30. [PubMed] [Google Scholar]